Twelve perinatal staff (five midwives and seven nurses) who work in perinatal services were recruited. All but one was over 30 years old and all were advanced diploma nurses or midwives; half of the participants had been employed in perinatal services > 10 years (Table 1).
Four heads of health centers participated in this study and two of them had > 5 years of experience in this role (Table 2).
Themes
Four main themes with their (sub-themes) were identified during the thematic analysis: (a) relational practice (being creative and flexible, “lending them our ears”); (b) individual challenges of providing care to adolescent mothers (lack of knowledge to provide care related to gender-based violence, and gendered experience); (c) factors contributing to workarounds (inflexible guidelines, lack of protocol and procedures, lack of nurses’ and midwives’ in service training, and physical structure of the perinatal environment); and (d) vicarious trauma (living the feelings, “I carry their stories home,” and hypervigilance in parenting) (Table 3).
Theme one: relational practice
When connecting with adolescent mothers in perinatal services, all nurses and midwives described caring for an adolescent mother as challenging. However, they also added that they try their best to care for the adolescent mothers by being creative and flexible and listening to the mother with empathy.
-
(a)
Being creative and flexible
Even though much of the care provided in perinatal services is routine, i.e., it is provided to every woman in perinatal services, nurses and midwives reported that there are additional demands which can be time-consuming when caring for adolescent mothers. For example, a few nurses and midwives reported that caring for an adolescent mother requires juggling multiple skills. One midwife said,
“It is challenging and time consuming. There can be a time when you can spend three hours without getting her consent for a single procedure such as a vaginal examination because she is mostly in pain.” (ME).
Another nurse described this experience as juggling multiple tasks. As they said,
“Ah, it’s tough to care for these adolescents; generally, it’s difficult. You have to deal with many things at once….
There is one [adolescent mother] that I received when examining her, she squeezed her legs together, refused completely, and I failed to examine her. I even approached the person who had brought her to help me, but it did not work. I told myself that instead of having a certain [negative] incident either for the mom or the baby, I’d rather transfer her to the hospital.”(ND).
Health center managers also noted that caring for adolescent mothers can take considerable time; in response they sometimes get involved helping nurses and midwives on duty. As one health center manager said,
“In morning reports, adolescent mothers are reported to give nurses/midwives a hard time. I have often been called during the day or at night to assist them with situations when a nurse/midwife spent long time negotiating with an adolescent without any positive results.” (KI3).
Nurses and midwives noted differences between caring for adolescent mothers and adult women which they tried to accommodate. Here, the nurse believed that the potential safety risk for the mother and baby should be addressed by transferring the adolescent mother to the district level for care. However, this would have added additional costs to the adolescent mother and the family, given the transportation payment and the costs associated with district hospital services.
One nurse stated that sometimes receiving an adolescent mother is challenging due to her complex needs. They added that when they receive the adolescents in ANC visits, they often have to counsel them for other issues such as abortion and suicidal ideation. A few of nurses and midwives ensure that adolescent mothers feel safe and are involved in care as explained,
“I counsel her to make her feel that you are together. I explain everything that giving birth is a process that requires her to put her efforts.” (NG).
Another midwife provides an example of being flexible when caring for an adolescent mother in the following:
“From the first time of receiving her up to discharge or referral, even after discharge, you have to expect that whatever you will do is quite different from other mothers. [For example] you have to deal with delayed consent before the procedures, and provide more explanations. So, you have to be patient!” (MD).
Some key informants (KIs) said they were responsible for reminding nurses and midwives about the importance of ensuring that adolescent mothers are safe and involved in their care. For example, as one KI noted,
“Well, of course, we always encourage our staff to consider adolescent mothers as special and to provide them with additional information to understand what is happening to them during their care.” (KI1).
Advocacy is another concept that emerged from the study participants’ narratives. Given the vulnerability of this patient population, e.g., financial instability, being judged and stigmatized and even abused in their communities and because there are no particular care guidelines related to the care of adolescent mother in perinatal services, some nurses and midwives felt they needed to advocate for proper care management and referrals. As one nurse notes in the following,
“I approach the head of the health center to find out how we can register the adolescent mother under the 1st category of community-based health insurance. Then the cost is paid by the district office.” (NC).
In a similar vein, another midwife speaks to advocacy in the following:
“There is a project which takes care of those adolescent mothers. We contact them and connect her with that project. They help her.” (MC).
In response to advocacy by nurses and midwives, some KIs helped adolescent mothers in these situations. As one KI said,
“I am always contacted by them [nurses and midwives] to inform me that they [adolescent mothers] cannot pay. We discuss how we can help.” (KI3).
Financial instability and the inability to pay for community health insurance is one of the biggest barriers to access perinatal services for adolescent mothers.
A few nurses and midwives reported engaging in interdisciplinary collaboration as a pillar in the proper management of adolescent mothers in perinatal services. They described caring for adolescent mothers as primarily the responsibility of nurses and midwives, however, they also pointed to the roles and importance of a nutritionist, community health officer, social worker, and a mental health nurse as part of perinatal care services. As one midwife said,
“In some cases, we decide that a nutritionist, a social worker and a community health officer work together to take care of vulnerable adolescents since they often come from poor families or are rejected.” (MB).
Another midwife added that mental health problems are more prevalent in perinatal services, and sometimes perinatal nurses’ and midwives’ skills in counselling are limited. For example, a midwife shared the experience of a 17-year-old adolescent mother who had been rejected by the father of her baby, resulting in mental health issues which required interdisciplinary collaboration. Because of the severity of her symptoms, the family brought her to the health center for counselling. This midwife added that it went beyond their capacity as nurses and midwives to provide this kind of care because their skills are limited. A midwife explained,
“There is a nurse in charge of mental health. When you realize that you may not be able to make good counselling sessions, you ask her for assistance. She works every day until Saturday.” (MC).
Even though these settings are in rural areas, having a mental health nurse working until Saturday was one of the strengths of the interdisciplinary team because they would serve adolescent mothers whenever they needed care. Understandably, working in an interdisciplinary team helped these nurses provide quality care to these adolescent mothers. In addition, it prevented adolescent mothers and their families from paying additional costs related to transfer to district hospitals for further management of mental health problems.
-
(b)
“Lending them our ears”.
The nurses and midwives interviewed discussed the need to ensure that adolescent mothers receive non-judgmental care. A few of them noted that active listening is a top priority. For example, as one nurse reported,
“I do not judge or blame them [adolescent mothers]. They had been and are still being blamed so much in the community and families. As a nurse, I must show her love and the difference and listen to them with sympathy.” (NE) A midwife added, “Hmm… one thing I found that is important is listening to them…. well, lending them our ears.” (MB).
, The quotes above exemplify how these nurses and midwives recognize the impact of family and community stigma on an adolescent mother’s life; they wanted to ensure the adolescent mothers felt full acceptance instead of judgement – listening was an essential element of that process.
Even though it is challenging to care for adolescent mothers in perinatal services, some nurses and midwives reported that they overcome these challenges by fostering connection and trust with the mother. A midwife shared how creating a positive relationship helped her care for an adolescent mother with several problems. She assisted a 15-year-old girl in the ANC who was impregnated by a local leader after promising her some school materials. According to the adolescent, this man beat and insulted her; she was traumatized and in response requested an abortion. However, the midwife spent time with the adolescent, explained the issue and the consequences that could follow so that she could make an informed decision. The adolescent mother agreed to give birth, and now she is happy with her baby and always comes to see that midwife. At delivery, the adolescent mother was referred to the district hospital for management. However, the relationship between the midwife and the adolescent mother continued to grow, as noted in the following quote:
“I found that the conversation we had made her come back looking for me, and now she keeps coming to see and tell me ‘see your baby.’ Now, her baby is my baby too… These words keep motivating me in my daily practice to form a connection and build a positive relationship with adolescent mothers.” (MB).
In the situation above, the midwife demonstrated that listening to this young mother and developing a positive relationship resulted in long term positive outcomes such as adolescent mother’s informed decision to go forward with the pregnancy and the care of her baby. The midwife considered keeping the pregnancy the only positive outcome, while abortion was considered a possible option by the adolescent mother.
Theme two: individual challenges of providing care to adolescent mothers
From the participants’ narratives, it was revealed that the majority of nurses and midwives perceived some challenges when connecting with adolescent mothers. These challenges included a lack of knowledge and skills, and a gendered experience.
-
(a)
Lack of knowledge to provide care related to gender-based violence (GBV)
Some nurses and midwives reported challenges which hindered the quality care of care provision with adolescent mothers, including gaps in knowledge and skills specific to GBV against adolescent mothers’ care. For example, a midwife in this study reported the following:
“I have no special knowledge of caring for an adolescent with a history of violence. I have to help her in every way possible, and I refer her to Isange One Stop Center, which would help her with anything. The only other knowledge I have to help these adolescent mothers is that if she does not accept giving birth, they can have an abortion. If she is a GBV case, she has the right to abort. Yeah, that’s it. I believe that my knowledge is not sufficient. I need sufficient knowledge because what I do is what I can help anyone else who is not an adolescent mother. For sure, I need to upgrade my knowledge and skills to take care of GBV cases.” (MB).
In this case, the midwife did not feel she had the ability to provide care adequately related to gender-based violence (GBV). The Isange One Stop Center supports the national efforts of the Ministries of Health, National Police and Justice to combat GBV. As the name Isange Centre implies, “feel free/feel welcome,” the center communicates a message of security and openness to survivors. A lack of specific knowledge was also reported by another participant,
“I talk to them [adolescent mothers] as a parent but [have] no other specific knowledge”” (ND).
A midwife notes her need in the following,
“Personally, knowledge isn’t a problem. What is needed in terms of knowledge is to ‘refresh,’ to do a refresher training on how to take care of this special population.” (MD).
KIs also reported nurses’ and midwives’ limited knowledge to care for adolescent mothers. Nurses and midwives are cognizant that adolescent mothers need special care because of their unique needs. Inconsistencies in care were related to the years of experience, time since finishing school, and/or academic background (i.e., midwifery vs. nursing). For example, the nurse participants we interviewed who recently graduated reported utilizing knowledge from school, while those more experienced providers found recalling information more challenging.
-
(b)
Gendered experience
All male nurses and midwives reported that caring for adolescent mothers is sometimes difficult. Several cases were described where adolescent mothers refused a male nurse or told male nurses/midwives not to touch them because they were male. As one male nurse said,
“Because I am a male health care provider, sometimes, they fear me. I have met with some [adolescent mothers] who refused me to examine them because I am a male provider. One told my female colleague that men are not serious. If she does not want, you don’t have to force, better to call female colleagues to help.” (NC).
In this similar context, the male midwife MD shared the story of a 15-year-old girl who came to give birth. While the girl was experiencing significant labor pain, he had to conduct a vaginal exam to ascertain the extent of dilation. He explained the process and the need to examine her, yet she refused. Upon further assessment, he realized that the girl was refusing to be examined because he was male so he called upon a female nurse/midwife who explained everything to the adolescent mother. All these nurses and midwives recognized that forcing the adolescent mothers could result in negative outcomes. Thus, they have been able to involve female providers to ensure the safety and comfort of their clients.
Theme three: factors contributing to workarounds
Most nurses and midwives reported the use of workarounds in perinatal care when caring for adolescent mothers as related to stringent guidelines, a lack of protocols and procedures and lack of nurses’ and midwives’ education and training and the unwelcoming nature of the perinatal care environment.
-
(a)
Inflexible guidelines
A few nurses and midwives reported that when caring for adolescent mothers in perinatal services, they follow guidelines that are not flexible; that is, they do not accommodate the needs of the adolescent mother. For example, adolescent mothers are mandated to bring their husbands or partners on their initial visit. This requirement can re-traumatize them because they often do not have or cannot locate their partners. According to Article 194 of the Rwandan Penal Code, anyone living with a child as a husband or wife faces life imprisonment. Therefore, it’s almost impossible to find these men/boys. One midwife noted,
“For their husbands, you cannot find any because they might be jailed because it is criminalized” (MB).
Most of the nurses and midwives have said that they do not see why they ask that and believe that this is something which can be changed for the sake of helping adolescent mothers. As one midwife said,
“Everyone you tell to bring a partner becomes unhappy and sometimes may cry.” (MB).
When asked why they ask adolescent mothers to bring their partners while they are sure that they cannot find them, she replied,
“That is how guidelines are structured. You have to follow them and tick in the register that you have done that.” (MB).
A nurse shares their response to the guideline as follows,
“If she doesn’t find a partner or I realize that if she goes back, she will not come back, I help her regardless of the rules. However, it’s not accepted. She should bring an authorization copy from the local authorities.” (NF).
However, the head of the health center KI3 said,
“So, here, we can’t ask them [adolescent mothers] to bring their husbands.” KI3.
These inconsistencies may be related to the type of services an adolescent mother will receive, either emergency or non-emergency. As a nurse noted,
“Sometimes they [adolescent mothers] don’t get services directly, especially if they do not have insurance, but the health center’s manager helps us to resolve these issues.” (NG).
and when asked why an adolescent mother does not get the services right away, they said,
“It delays because we need to inform the health center head that adolescent mothers do not have health insurance. So, it may take some time to sort it out.” (NG).
In the cases noted above, nurses and midwives knew the guidelines were inflexible and bypassed them to help the adolescent mothers. Nurses and midwives recognized the negative effects of sending adolescent mothers back to community health workers or executives of the community cell to bring a confirmation paper that provided a reason why they could not attend clinic with their husbands. Thus, they chose to help them get services instead of sending them back to the community.
-
(b)
Lack of protocols and procedures specific to adolescent mothers
In this study, nurses and midwives noted the tensions and disjunctures created between the guidelines re: perinatal care and what adolescent mothers needed. They expressed concern that the existing guidelines contain insufficient information, often limited to just a single paragraph. They emphasize that caring for an adolescent mother involves addressing the needs of a whole person who often requires more care than other mothers. This inadequacy in guidelines makes it challenging to provide appropriate care, leaving nurses and midwives uncertain about the effectiveness of their support. For example, as one nurse said,
“We do not have special guidelines or protocols for adolescent mothers. In the guidelines, some information about adolescent mothers is insufficient. You will find that it’s only one paragraph, but when you take care of an adolescent mother, it’s a whole person who even needs more care than other mothers. It’s challenging and sometimes you are sure that, even though you helped her [adolescent mother], you did not do it appropriately.” (NA).
The health center managers underscore the absence of the necessary and written guidelines for caring for adolescent mothers. They point out the need for detailed, step-by-step protocols that guide nurses and midwives on how to receive and communicate with adolescent mothers. They also suggest that such instructions should be displayed in offices to serve as references during consultations so staff can access them easily. For example, as one head of the health center noted,
“No charts are available. We do not have the written instructions to show us how to care for an adolescent mother from point a, b, c…. How to receive and talk to them …Yet they should be hung somewhere in the offices to be used as references during consultations, as protocols and guidelines so that it is well-known what to do.” (KI4).
-
(c)
Lack of on job training for nurses and midwives
Some nurses and midwives highlighted a lack of special training as challenges they face in their daily practices in perinatal services when connecting with adolescent mothers. They emphasized the need to update their knowledge since they still rely on school-level knowledge. As one midwife reported,
“We do not receive any on job training [caring for adolescent mothers] except for what we learn in a school, deemed to be not sufficient.” (MA).
In this similar context, some participants added that since they lack this knowledge and skills, they must wait for specialized providers such as mental health nurses or social workers to provide support. They noted how waiting for providers with specialized skills can impact care provision since they do not have enough or are not always available at the health center. For instance, as one nurse said:
“We all [healthcare providers] need the training to care for adolescent mothers. There is a time when you receive them and realize you are not trained; it’s an arrangement. We need that training to not wait for those in charge of mental health or with additional training to help adolescent mothers.” (ND).
A number of health center managers have acknowledged the need for nurses and midwives to receive specific education and training related to the care of adolescent mothers in perinatal services in order for them to feel prepared and confident in this area of practice. For example, one health center manager noted,
“We can’t say we had a special experience because we didn’t get in-depth training to care adolescent mothers. We got trained a few times, and it is not enough.” (KI4).
There is a risk that some nurses and midwives might not be able to respond to the potential effects of trauma and ongoing violence and handle disclosure appropriately due to their lack of knowledge and skills in this domain. It is noteworthy that from the participants’ narratives, the approaches to adolescent mothers vary. In addition, their lack of skills is a potential cause of re-traumatization. For example, as one nurse reported,
“If you force her [adolescent mother] to talk, you can hurt her in one way or another.” (NG).
In a slightly different vein, a health center manager noted,
“I have witnessed some cases where nurses and midwives sometimes fail to interact with adolescent mothers because they could not know some trauma signs and symptoms.” (KI4).
-
(d)
Physical structure of the perinatal environment
A few nurses and midwives also highlighted the challenges they face maintaining confidentiality as associated with the services and structure of the clinics. For example, when adolescent mothers leave the health center for the first time, like other mothers, they are given some medical materials such as insecticide-treated bed nets (ITNs) for malaria prevention and other medical supplies. In the community, ITNs from the hospital signals that you are pregnant. As one midwife noted in the following,
“They are reluctant to take them [ITNs] home, saying whoever sees them will think they are pregnant.” (MD).
Nurses and midwives said they struggle to convince the adolescent mothers that the important thing is the health of their babies and themselves and sometimes they find a way to help assist with this. For example, this midwife will sometimes buy an envelope so to conceal the ITNs. However, teaching about the advantages of ITNs for the health of the adolescent mothers and their babies is a challenge given this reality. The study participants reported that many of these adolescent mothers exhibit a reluctance to sit with other mothers in the common waiting areas of the perinatal services, i.e., ANC. They often approach the nurses and midwives, expressing a desire to speak privately seeking arrangement for not sitting in the common areas with other women who may be their neighbors. This behavior is consistently driven by feelings of stigma related to their pregnancies. To accommodate these concerns, the nurses and midwives typically lead the adolescent mothers to a different entrance, demonstrating a sensitivity to their need for privacy and a supportive approach to their care, even though the environment itself is not set up in a way that supports this. A midwife provided an example related to the perinatal environment in the following quote:
“I have seen many adolescent mothers coming and not sitting with others. They see me and say hey, I want to tell you something. They all had the same issue of wanting to avoid sitting in the waiting area with others. Immediately I led them to another entrance; you saw that we have two doors, an entrance and an exit. They usually tell me they are worried, ashamed and afraid of what they have experienced.”(MC).
Some nurses and midwives expressed a need for specialized and sensitive approaches in their practice, especially to support the adolescent mothers’ unique needs. They gave examples of some primary healthcare settings services, where patients are provided with a separate seating arrangement to ensure privacy and reduce stigma. Similarly, they advocated for creating special spaces for adolescent mothers, suggesting that these adolescent mothers should be received in areas with separate entrances and exits. This setup would help maintain their privacy, enhance their comfort, and provide a more supportive environment tailored to their unique needs. As participants suggested:
“It should be done like in anti-retroviral therapy (ART) services, for example. Those who come for medication in the ART service are sitting on their own; they don’t make them sit with others who come for a routine check-up.” (NE).
“They [adolescent mothers] should be received in a place where there is an entrance different from the exit because it helps them.” (MD).
“These adolescent mothers are ashamed of sharing the waiting areas with others since they do not want them to know what they are doing there. It would be better to have their areas for ANC or even separate exit doors so that no one sees them returning from these services.” (KI1).
Theme 4: vicarious trauma
The majority of nurses and midwives interviewed in this study became involved emotionally with adolescent mothers and noted they are often consumed with thoughts about the adolescent that seep into their personal lives. They reported that sometimes they live the feelings of adolescent mothers, become depressed or project the same stories onto their own children, and become hypervigilant in parenting.
-
(a)
Living the feelings
A few nurses and midwives reported that during the conversations with adolescent mothers, they sometimes feel emotionally exhausted by the contextual features of the adolescents’lives.
The study participants experience significant emotional and psychological challenges in their roles of caring for adolescent mothers. They often feel deeply saddened and shocked by the cases they encounter. The continuous experience of the adolescent mothers’ problems in their minds leaves them feeling helpless and unable to find ways to console them, often leading to feelings of being traumatized. A midwife shared the story of a 17-year-old who went on a trip with her female friends who had also invited boys. The adolescent mother was raped repeatedly after being locked in a room. Thus she did not know the father of her baby. Her family rejected her, and she wandered on the streets. This midwife said,
“I heard that case, and I felt so sad; it touched my heart, and I felt shocked.” (MD).
Another nurse notes,
“All their [adolescent mothers] problems accumulate in my head, and I could not find ways to console them. It’s challenging and traumatizing.” (NC).
-
(b)
‘I carry their Stories Home’.
Some nurses and midwives said that adolescent mothers’ stories negatively affect them to the extent that they become depressed or project the same stories onto their children. They said that when they are home or outside work, they continue to think about the adolescent mothers’ stories. For example, as one midwife noted,
“Absolutely! It’s challenging for me because I also have adolescents, which affects me. When I leave seeing a case like that, I immediately imagine it on mine… So I directly see that it has affected me because I go and take more time to teach mine or even take time to think if it had happened to mine. Sometimes I spend a long time thinking about that. You might be upset or even cry alone.” (MB).
Carrying these stories outside the perinatal environment, crying alone and projecting them onto their children, signals that caring for adolescent mothers can sometimes be traumatizing for the provider.
-
(c)
Hypervigilance in parenting
Four nurses and midwives reported that they sometimes do not trust males who approach their daughters or close female family members because of what they experience when caring for adolescent mothers. Others do not wish to understand that their daughters are dating. One midwife said that because of caring for adolescent mothers and hearing the stories, for example of being raped by their family’s friends or even by family members, they [the midwives] don’t want their daughters to have relationships with any males. This midwife said,
“As a parent, I am now not happy to see any male who starts these relationships with my daughter. Their [adolescent mothers] family’s friends, neighbours and even some family members are the ones who impregnated them.” (MB).
Another nurse said that when they teach their children or others, they refer to those stories, especially emphasizing that men as perpetrators should be accountable for their actions. As one nurse said sadly (with an angry face),
“I do not tolerate these problems… I, personally when teaching my daughters, should emphasize on avoiding men; they are the ones who cause the problems.” (NG).
As these narratives illustrate the consequences of vicarious trauma can be far reaching – even into the personal lives of the healthcare providers.
Even though nurses and midwives are at risk of vicarious trauma, when we asked their heads of health centers about the available programs to protect their staff from vicarious trauma, they said they do nothing. For example, the KIs in the following said,
“There’s nothing special based on our administration structure.” KI2.
“I don’t think we have this service for nurses and midwives. They have their own ways of taking care of themselves.” KI1.
These quotes reflect that there is a lack of support for perinatal healthcare providers who are at risk of developing vicarious trauma.
Add Comment